Illnesses > Illnesses in Older Children > Chronic Constipation

Chronic Constipation

Sometimes children develop a pattern of stool withholding, which results in chronic constipation.  If a child develops a pattern of avoiding stooling, either because of painful bowel movements or because of control battles with parents, the stool can become dry, hard, and packed in the colon.  Even if the child then begins to stool daily, the “pipe line” may remain full.  Crampy abdominal pain can be the result.  This is generally a behavioral problem, rather than a medical or dietary problem.  
When chronic constipation is diagnosed:

1. At all costs, avoid potty battles with the child if not already potty trained.  All attempts at potty training must immediately be halted.  Younger children may be given the choice to wear diapers again.

2. During acute moments of pain, child or adult size glycerin suppositories may be administered, one every 20 to 30 minutes by rectum (up to 3 times) until a stool is passed and the child is more comfortable.  Occasionally a pediatric Fleet’s Enema may be necessary if recommended by the physician.

3. The stool must be made soft, easy to pass, and painless.  Softening the stool with mild medications is not habit forming, even over long periods of time; they work simply by drawing more water into the stool.  (But avoid “laxative” products, which might be habit forming.)  

Stool softeners must be used for long enough that the child essentially forgets the fear of pain with stooling, which may take several months.
You may use Miralax® or a fiber product such as Metamucil®, Citrucel®, or Benefiber®.  Use the same product that adults would use.  Generic versions work just as well, and cost less.
You can mix the fiber or Miralax into water, milk, or any other liquid, or even in food.  It may take longer to dissolve than you expect.  To make it easier to drink, let it sit and dissolve for an hour or two, or even overnight.
Use as much as needed to make every stool soft.  The amount of the softening agent should be slowly increased as follows:  (½ capful of Miralax is equivalent to 1 Tablespoon of a fiber product.)
½ capful per day for three days
1 capful per day for three days
1½ capful per day for three days.
Then increase as needed until the stool is soft.  (There is no “maximum” dose; use as much as needed.)  Once the stool is soft, that dose of medication should be continued for at least 2 months.  Once the stools have been regular and easy to pass for at least 2 monthseks, the dose can be slowly decreased.  If hard stools develop again, increase the dose again.
Stool softeners must be used every day, not simply when hard stools are noticed.  It can take a couple of days for the Miralax to travel to the colon and do its work; if it’s given only every other day, then the child will be constipated every other day.
Sometimes, the stool softener may be required for several months at a time; this is absolutely not harmful or habit forming.
4. Regular stool habits should be encouraged.  Older children who are potty trained may decide that they don’t want to have a stool often enough.  Perhaps they are proud of themselves for being potty trained and want to exercise their ability; perhaps the bathrooms in school are unappetizing; or perhaps they simply get “too busy” to go.  
In any event, you can avoid this problem by having the child sit on the toilet every day, after breakfast and after dinner, as a regular habit.  This permits the child to have a specific time when they are not interrupting another activity.  Also, everyone has a reflex that when the stomach is filled with food, the rest of the intestines move along to make room.  A sticker chart may encourage the child’s cooperation.
These simple maneuvers, practiced consistently over time, should teach good bowel habits without unnecessary family control issues.

© David M. Epstein MD, 2008, 2018